SLIT LAMP MICROSCOPY

SKILL SESSION
The evaluation of all eye complaints begins with the history.
All patients with eye complaints should have their visual acuity checked.
Tetanus status
R/O
alkali/chemical burn - irrigate immediately
central retinal artery occlusion - massage, acetazolamide, timolol, (and paracentesis)
globe perforation (Seidel Test/Sign*)
The use of fluorescein in a case of a perforated corneal
ulcer to demonstrate a positive Seidel Test. Aqueous
humor leaking through the corneal opening quickly
dilutes the applied fluorescein which is seen a moment
later being washed down the surface of the cornea.
(from Martonyi et al, Fig 103.)
Pharmacology
Local anesthetics
amides
generic name brand name
lidocaine Xylocaine

esters (If a patient is allergic to local anesthetics, it will probably be this class.)
procaine Novocaine

tetracaine Tetracaine

, Pontocaine

proparacaine (refrigerate) Alcaine

, Opthane

Cycloplegics / mydriatics
generic name brand name duration
tropicamide (ophthalmologist dilation) Tropicacyl

, Mydriacil

4 - 6 hours
cyclopentolate Cyclogyl

, AK - Pentolate

1 day
homatropine Isopto Homatropine

1 - 2 days
scopolamine Isoptohyoscine

1 - 2 days
atropine Isopto Atropine

1 - 2 weeks
Mydriatics are red-topped.
Meiotics, like pilocarpine for acute angle closure glaucoma, are green-topped.
Do not prescribe eye drops containing cycloplegics, topical anesthetics, or steroids.
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Slit lamp technical points to remember.
Align (roughly) the eyes with the black line on the microscope.
The patient!s head must abut the headrest. This is the most likely source
of error.
Fluorescein staining
Use the cobalt blue lamp to check for corneal defects.
The cobalt blue lamp is similar to the !black light" from your undergraduate days.
The red-free filter has a blue-green appearance.
A patient who complains of a FB sensation has a corneal abrasion. This is very
common.
The light should be obliquely oriented, and !wide open", initially. If a stained defect is not
readily apparent, narrow the slit to detect a small defect.
Blinking will dilute the dye.
Focus on the cornea, not the iris. When the patient blinks, the fluorescein film layer is readily
apparent.
White light
Flip the lid to r/o FB. Have the patient look down to relax the levator palpebrae muscle.
Have the patient look up and the lid will easily flip (spontaneously) into place.
Penlight Screening Test for Acute Angle Closure Glaucoma
From Knoop, Stack, and Storrow
Fig 2.23 (in their second edition)
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The Anterior Chamber: Acute Angle Closure Glaucoma and Iritis (cell and flare)
Slit lamp: Use a thin stripe, obliquely oriented, to check the depth of the anterior chamber.
Penlight: See picture on previous page.
(The two figures below are modified from Martonyi et al.)
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Figure 64-45 from Roberts and Hedges, 4th edition
Cell and flare - Iritis appears as the !beam of a car"s headlight" when the slit lamp"s light passes
through the anterior chamber. Focus initially on the iris, then pull back on the joystick to focus within
the anterior chamber.
A flare within the aqueous humour is the result of an abnormally
high concentration of protein from the leaking intraocular blood
vessels together with some local synthesis of immunoglobulin. It
defines the slit-lamp beam within the anterior chamber rather like
a car headlight cutting through a foggy night. A flare will usually
be found in the presence of cells, although it often remains within
the aqueous humour for some time after the cells have
disappeared and is then an indication of persisting vascular
damage rather than active inflammation.
(Modified from Spalton et al, Fig 10-3.)
Flare is seen between the points A and B.
Aqueous cells and flare.
Flare is seen (subtly) between points B and C, more so at point
B.
(From Martonyi et al, Fig 36.)
Flare is more easily seen here (AC - anterior chamber).
(Modified from Knoop, Stack, and Storrow, Fig 2.27, who stole it from
Spalton, Hitchings, and Hunter.)
Cells in the anterior chamber are a sign of inflammation or
bleeding and appear similar to particles of dust in a sunbeam.
They are best seen with a narrow slip-lamp beam directed
obliquely across the anterior chamber.
(From Knoop, Stack, and Storrow, Fig 2.26. They stole this one too from
Spalton, Hitchings, and Hunter.)
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References
Berson FG. Basic Ophthalmology for Medical Students and Primary Care Residents
Sixth edition. American Academy of Ophthalmology. 1994
Brandreth RH. Clinical Slit Lamp Biomicroscopy 1978
Cullom RD and Chang B. The Wills Eye Manual - Office and Emergency Room Diagnosis and
Treatment of Eye Disease J.B. Lippincott Second edition 1994
Knoop KJ, Stack LB, and Storrow AB. Atlas of Emergency Medicine
McGraw-Hill Second edition 2002
Knoop KJ, Trott A. Ophthalmologic Procedures in the ED, AEM 1994-5
Part I: Immediate Sight-saving Procedures. 1(4) p 408
Part 2: Routine Evaluation Procedures. 2(2) p 144
Part 3: Slit Lamp Use and Foreign Bodies. 2(3) p 224
Martonyi CL, Bahn CF, and Meyer RF. Clinical Slit Lamp BIomicroscopy and Photo Slit Lamp
Biomicrography Time One Ink, Ltd. Second edition 1985
Roberts JR and Hedges JR. Clinical Procedures in Emergency Medicine
Saunders Fourth edition 2004
Spalton DJ, Hitchings RA, and Hunter PA. Atlas of Clinical Ophthalmology
Wolfe Publishing Second edition 1994
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Diagram of the corneal parallelepiped
ABCD represents the anterior surface of the cornea.
EFGH represents the posterior surface of the cornea.
BDFH represents the cornea in cross-section.
There is essentially no separation between
the cornea (short arrows) and the iris (long
arrows). The anterior chamber is
essentially absent. (adapted from Martonyi et al)